MEDICARE: MELYSSA GAYLE WIGGINS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.018935	IL

General Provider Information

NPI Number	:	1245798347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELYSSA GAYLE WIGGINS FNP

Provider Business Mailing Address
First Line	:	11489 STATE ROUTE 14
Second Line	:
City	:	MC LEANSBORO
State	:	IL
Zip	:	62859-2195
Country	:	US
Telephone Number	:	618-925-0417
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 S WASHINGTON ST
Second Line	:
City	:	MC LEANSBORO
State	:	IL
Zip	:	62859-1139
Country	:	US
Telephone Number	:	618-643-2835
Fax Number	:	618-643-2891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2019
Last Update Date	:	03/07/2019

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